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gests that the preservation of the duodenum, and a small amount of the pancreatic headmay have a profound benefit on the postoperative course of the patient
Alternative Treatments
Pancreatic resection is the only treatment modality which offers the possibility for cure
in pancreatic cancer However, distant metastases, and advanced local disease are indications to resection Also, resection should be avoided in patients with acute orchronic diseases that may make the risk of surgery and anesthesia prohibitive Tissuediagnosis may be obtained in these cases through percutaneous methods, by ERCP, orEUS Biliary and duodenal obstruction may be treated with either surgical bypass or withendoscopically placed stents
contra-In contrast, chronic pancreatitis is primarily a medically managed disease Surgery isindicated when medical treatment fails or when endoscopic methods are unsuccessful inthe treatment of an obstructed pancreatic duct Medical treatment of chronic pancreatitisincludes pain management, and patients are encouraged to abstain from alcohol Notonly does this remove the cause of chronic pancreatitis, but alcohol is also a secretagog,and can stimulate an already compromised organ In order to avoid overstimulating thepancreas, small meals containing low amounts of fat and protein are advised To furtherrest the pancreas, some have prescribed acid-suppressing agents, pancreatic enzymes,and octreotide, a somatostatin analog Although these measures make physiologicalsense, they have not been definitively proven to be of benefit in the long-term treatment
of chronic pancreatitis
Pain management includes analgesics as well as analgesia-enhancing drugs NSAIDSand acetaminophen are first used However, narcotics are usually required for adequatepain control Celiac plexus block is effective in pancreatic cancer, but is not as effective
in chronic pancreatitis because of the reluctance to use permanent neurolytic agents.Procedure-related complications include transient hypotension, nerve root pain, andfocal neuropathic damage
Endoscopic treatment of chronic pancreatitis is also possible Strictures in the mainpancreatic duct may be amenable to pancreatic duct stenting, with an efficacy of 66%
reported in some series (20–26) However, this is also associated with its own set of
complications including cholangitis, hemobilia, stent occlusion, stent migration, ductal infection, duodenal erosions, and ductal perforation Long-term complicationsinclude morphologic changes of the pancreatic duct, which can lead to strictures Stentsalso need to be replaced, and therefore, do not provide long-term symptomatic relief that
intra-a surgicintra-al drintra-ainintra-age procedure cintra-an provide
Pancreatic ductal stones may also be removed endoscopically This technique is bestwhen the stones are small and limited to the pancreatic head Impacted stones may befragmented first by lithotripsy
Endoscopic therapy is, therefore, an acceptable short-term treatment of symptomsfrom chronic pancreatitis It may be appropriate therapy for patients who are high sur-gical risks, but further studies are needed to compare medical, endoscopic, and surgicaltreatment of chronic pancreatitis
Cost
The cost of duodenal-preserving pancreatic head resection in one series was $23,000
+ $16,500 The disease-specific hospital cost decreased after surgery by 57% (18) ThisThis is trial version
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is attributed to reduced pain score and hospital admission rate Also, the occupational
rehabilitation rate is between 68 and 75% (16,18).
L ONGITUDINAL (S IDE - TO -S IDE ) P ANCREATICOJEJUNOSTOMY (P UESTOW P ROCEDURE )
Pain in chronic pancreatitis may be caused by obstruction and dilatation of the creatic duct Early surgical approaches developed for decompression included biliarysphincterotomy, and caudal drainage of the pancreas to a loop of jejunum (Duval pro-cedure) However, because multiple strictures and dilatation of the pancreatic duct occursthroughout the ductal system, Puestow advocated a method for wider decompression in
pan-1960 This involved opening the pancreatic duct from the neck of the pancreas to the tail.The entire distal pancreas was then invaginated into a jejunal loop for enteric drainage
of the distal gland This approach was modified by Partington and Rochelle who formed a side-to-side, Roux-en-Y, pancreaticojejunostomy (Fig 7)
per-The advantage of this procedure, still known as a Puestow procedure, is that there is noremoval of pancreatic parenchyma and, therefore, no risk of additional endocrine or exo-crine insufficiency However, this procedure can only be performed if dilated ducts arepresent Long-term follow-up studies show pain improvement in 70–80% of the patients
(27–32) A decompression procedure prevents or delays the progression of pancreatic
insufficiency when compared to medically treated obstructive chronic pancreatitis (33).
Procedure
The procedure begins with an exploration of the abdomen to rule out a malignancy Thepancreatic duct is then located by palpation and confirmed by needle aspiration of pancre-atic fluid An intraoperative ultrasound may also be used for pancreatic duct localization.Following this, the pancreatic duct is then splayed open from the pancreatic tail to as close
to the entry into the head as possible (Fig 7A) All ductal stones are removed A jejunallimb is anastomosed to the open pancreatic duct (Fig 7B) and bowel continuity is re-established in a Roux-en-Y fashion (Fig 7C)
Complications
The Puestow procedure has a reported mortality rate of 4%, and a complication rate
between 10–15% (27–33) Because pancreatic parenchyma is preserved, endocrine and
exocrine insufficiency is not exacerbated Despite the fact that a longitudinalpancreaticojejunostomy is a safe procedure, long-term mortality remains high with a5-yr survival as low as 40% This is attributed to continued alcoholism, and comorbidconditions Recurrent inflammatory changes occur in 15–20% of patients, as a result ofobstruction and persistent disease in the pancreatic head.This is trial version
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L ONGITUDINAL P ANCREATICOJEJUNOSTOMY WITH E XCAVATION
OF THE P ANCREATIC H EAD (F REY P ROCEDURE )
As the pancreatic duct dives posteriorly into the head of the gland, adequate pression with a longitudinal pancreaticojejunostomy alone is difficult The Frey proce-dure, with excavation of the proximal gland, is used especially in cases where thepancreatic head is enlarged as seen in most cases of chronic pancreatitis
decom-Procedure
The Frey procedure is a modification of the longitudinal pancreaticojejunostomyprocedure, where a duodenum-preserving excavation of the head of the pancreas is alsoperformed The tissue overlying the ducts of Wirsung and Santorini in the head is resected,and the duct to the uncinate process is resected or opened along its axis A side-to-sidepancreaticojejunostomy with a Roux-en-Y loop of jejunum is performed similar to thePuestow reconstruction (Fig 6)
Fig 7 Puestow procedure (A) Opening of pancreatic duct (B) Anastomosis of pancreatic duct
to jejunal limd (C) Roux-en-Y pancreaticojejunostomy.
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Complications
The late mortality is reported to be 10% and progression of diabetes occurred in 11% (17).
Roux-en-Y (Side-to-End) Pancreaticojejunostomy
A Roux-en-Y (side-to-end) pancreaticojejunostomy is used for internal drainage ofpancreatic duct leaks that may result from trauma, surgery, or acute pancreatitis Pan-creatic leaks that occur at the body and tail of the pancreas may be treated with a distalpancreatectomy However, a leak from the pancreatic duct in a chronically inflamedpancreas may be more safely managed with a Roux-en-Y pancreaticojejunostomybecause resection of the pancreas in this setting carries a higher risk of morbidity.The procedure involves creating a Roux-en-Y limb of jejunum, and suturing it to thearea of injury or leak on the pancreatic capsule, so as to provide internal (enteric) drain-age of the ductal secretions
Cost
The cost of longitudinal pancreaticojejunostomy is highly variable because of the
con-founding problems aforementioned The reported cost in the literature is $24,000 (27).
Summary
A longitudinal pancreaticojejunostomy is a safe procedure for chronic pancreatitiswith low morbidity and mortality in the immediate postoperative period However, thelong-term quality of life may be diminished by alcoholic recidivism or by ongoingpancreatic insufficiency
PSEUDOCYST DRAINAGE
A pancreatic pseudocyst is a fluid collection within or adjacent to the pancreas with
a surrounding wall of fibrous tissue lacking an epithelial lining Pseudocysts may occurafter pancreatitis or pancreatic trauma They may remain asymptomatic or may causepain They may also cause symptoms from gastric or duodenal compression such as earlysatiety, nausea, and vomiting Compression of the biliary system may lead to obstructivejaundice Portal hypertension can result from thrombosis of the splenic vein owing topseudocyst compression Additionally, pancreatic pseudocysts may cause hemorrhageeither from the inflammatory pseudocyst wall or from erosion of the pseudocyst into aperipancreatic vessel Peritonitis may occur following pancreatic pseudocyst rupture
Indications and Contraindications
The indications for surgery are somewhat controversial Surgical drainage is thepreferred method for all symptomatic pseudocysts larger than 5 cm, which are notamenable to endoscopic, transgastric drainage Surgery probably is the treatment ofchoice for recurrent pseudocysts, pseudocysts associated with common bile duct steno-sis or duodenal stenosis, pseudocysts that penetrate through the transverse mesocolon orextend into the mediastinum or lower abdomen, and for cystic lesions where a cysticneoplasm cannot be ruled out
There are four techniques described for surgical drainage of a pseudocyst: externaldrainage, cystogastrostomy, cystoduodenostomy, and cystojejunostomy The choice ofThis is trial version
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technique is based on the anatomical position of the pseudocyst The pseudocyst isgenerally drained into the segment of the gastrointestinal tract to which it is denselyadherent, or by means of a Roux-en-Y limb of jejunum
E XTERNAL D RAINAGE
External drainage of a pseudocyst involves placing a large bore catheter into thepseudocyst cavity, and draining it out through the skin (Fig 8) External drainage of apseudocyst is not generally the treatment of choice during an open procedure It is asso-
ciated with a mortality rate of 10%, and a recurrence rate of 18% (34) The risks include
hemorrhage from abrasion of the drainage tube, development of a pancreatic fistula, andsecondary infection It is only used when the surgeon finds that the pseudocyst is franklyinfected or thin-walled Either of these would make an anastomosis at risk for dehiscence
C YSTOGASTROSTOMY
Cystogastrostomy is utilized when the pseudocyst is adjacent to the posterior gastricwall It is best used when the pseudocyst is already adhered to the stomach, otherwise,most surgeons would recommend a cystojejunostomy instead Splenic vein obstruction is alsorelative contraindication to this procedure because it predisposes to postoperative bleeding.Cystogastrostomy is performed by making an incision in the anterior wall of thestomach (Fig 9A) An opening is then made on the combined posterior gastric, andpseudocyst wall (Fig 9B,C) and gastrostomy is closed (Fig 9D) The procedure has beendescribed as an open technique, as a laparoscopic method, or as a combined endoscopicand laparoscopic procedure
C YSTODUODENOSTOMY
A cystoduodenostomy is the procedure of choice when the pseudocyst abuts themedial wall of the duodenum (Fig 10) This is performed by first mobilizing the duode-num and pancreatic head with a Kocher maneuver (Fig 10A) An incision is made on thelateral wall of the duodenum If there is less than 1 cm from the medial wall of the duo-denum to the pseudocyst, then one can proceed with the cystoduodenostomy An inci-sion is made on the medial wall of the duodenum, being careful not to injure the ampulla(Fig 10B) This is carried down to the pseudocyst while avoiding the common bile duct,anterior and posterior gastroduodenal arteries If there is a substantial amount of pancre-atic parenchyma between the medial duodenal wall and the pseudocyst, a cystojejun-ostomy is usually performed instead (Fig 10C)
C YSTOJEJUNOSTOMY
A cystojejunostomy is performed if the pseudocyst is not adjacent to the stomach
or the duodenum A wide anastomosis is made between the pseudocyst, and the en-Y jejunal limb (Fig 11) In all surgical drainage procedures, the contents of thepseudocyst are thoroughly excavated, and a biopsy of the cyst wall is obtained to confirmthe diagnosis
Roux-Complications
The mortality rate for the internal drainage procedures are between 0 and 5% (2% for
cystogastrostomy, 1.9% for cystojejunostomy, and 0% for cystoduodenostomy) (34).
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Fig 8 External drainage of pancreatic pseudocyst.
Fig 9 Cystogastrostomy (A) Anterior gastric wall incision (B) Posterior gastric wall incision (C) Creation of cystogastrostomy (D) Gastrostomy closure.This is trial version
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Fig 10 Cystoduodenostomy (A) Duodenum and pancreatic head mobilization (B) Incision of
medial duodenal wall (C) Creation of cystoduodenostomy.
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Summary
1 Pancreatic pseudocysts are amylase rich fluid collections as a result of acute pancreatitis
or pancreatic trauma
2 The majority of these cysts resolve without any treatment
3 Treatment is indicated in large symptomatic pseudocysts
4 Several surgical and endoscopic therapies are available for the management of pseudocysts
5 The choice of pseudocyst drainage procedure depends upon the site of pseudocyst, ability of surgical and endoscopic therapy, and general condition of the patient
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10 Brennan MF, Moccia RD, Klimstra D Management of adenocarcinoma of the body and tail of the pancreas Ann Surg 1996;223:506–512.
11 Fabre JM, Houry S, Manddrsheid JC, et al Surgery for left-sided pancreatic cancer Br J Surg 1996;83: 1065–1070.
12 Sugiyama M, Atomi Y Pylorus-preserving total pancreatectomy for pancreatic cancer World J Surg 2000;24:66–70.
13 Karpoff HM, Klimstra DS, Brennan MF, et al Results of total pancreatectomy for adenocarcinoma
of the pancreas Arch Surg 2001;136:44–47.
14 Wagner M, Z’graggen K, Vagianos CE, et al Pylorus-preserving total pancreatectomy Early and late results Dig Surg 2001;18:188–195.
15 Beger HG, Schlosser W, Friess HM, et al Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease: a single-center 26-year experience Ann Surg 1999;230: 512–519; discussion 519–23.
16 Izbicki JR, Bloechle C, Knoefel WT, et al Duodenum-preserving resection of the head of the pancreas
in chronic pancreatitis A prospective, randomized trial Ann Surg 1995;221:350–358.
17 Frey CF, Amikura K Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis Ann Surg 1994;220: 492–504; discussion 504–507.
18 Howard TJ, Jones JW, Sherman S, et al Impact of Pancreatic Head Resection on Direct Medical Costs
in Patients with Chronic Pancreatitis Ann Surg 2001;234:661–667.
19 Slezak, L, Andersen DK Pancreatic Resection: Effects on Glucose Metabolism World J Surg 2001;25: 452–460.
20 McCarthy J, Geenen JE, Hogan WJ Preliminary experience with endoscopic stent placement in benign pancreatic diseases Gastrointest Endosc 1988;34:16.
21 Grimm H, Meyer WH, Nam VC, et al New modalities for treating chronic pancreatitis Endoscopy 1989;21:70–74.
22 Cremer M, Deviere J, Delhaye M, et al Stenting in severe chronic pancreatitis:results of medium-term follow-up in seventy-six patients Endoscopy 1991;23:171–176.
23 Kozarek RA Chronic pancreatitis in 1994: is there a role for endoscopic treatment? Endoscopy 1994; 26:625–628.
24 Binmoeller KF, Jue P, Seifert H, et al Endoscopic pancreatic stent drainage in chronic pancreatitis and
a dominant stricture: long-term results Endoscopy 1995;27:638–644.
25 Ponchon T, Bory RM, Hedelius F, et al Endoscopic stenting for pain relief in chronic pancreatitis: results of a standardized protocol Gastrointest Endosc 1995;42:452–456.
26 Smits ME, Badiga SM, Rauws EA, et al Long-term results of pancreatic stents in chronic pancreatitis Gastrointest Endosc 1995;42:461–467.
27 Kalady MF, Broome AH, Meyers WC, et al Immediate and long-term outcomes after lateral pancreaticojejunostomy for chronic pancreatitis Am Surg 2001;67:478–483.
28 Prinz RA, Greenlee HB Pancreatic duct drainage in 100 patients with chronic pancreatitis Ann Surg 1981;194:313–320.
29 Wilson TG, Hollands MJ, Little JM Pancreaticojejunostomy for chronic pancreatitis Aust NZ J Surg 1992;62:111–115.
30 Bradley EL Long-term results of pancreaticojejunostomy in patients with chronic pancreatitis Am
34 Bumpers HL, Bradley EL Treatment of pancreatic pseudocysts In: Howard J, Idezuki Y, Ihse I, et al., eds Surgical Diseases of Pancreas Williams & Wilkins, Baltimore, MD, 1998, pp 423–432.
35 Sharma SS, Bhargawa N, Govil A Endoscopic management of pancreatic pseudocyst: a lon-term follow-up Endoscopy 2002;34:203–207.This is trial version
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36 Lo SK, Rowe A Endoscopic management of pancreatic pseudocysts Gastroenterologist 1997;5:10–25.
37 Beckingham IJ, Krige JE, Bomman PC, et al Endoscopic management of pancreatic pseudocysts.Br
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inci-50% of cases of moderate to severe pancreatitis should not be confused with pancreatic
pseudocysts, as more than 50% of these lesions resolve spontaneously (1,4) These occur
as a result of an exudative reaction to pancreatic injury and inflammation, and do notcommunicate with the pancreatic duct, and therefore, do not contain a high concentration
of pancreatic enzymes In addition, they do not possess a well-defined wall, and there is
a loss of an interface between the fluid and adjacent organs Approximately 10–15% maypersist beyond 3 wk, at which time they may develop a capsule and may be diagnosed
by ultrasound or computed tomography (CT) scan as a pancreatic pseudocyst (5).
TRANSPAPILLARY CYSTIC DRAINAGE (TCD)
TRANSMURAL OR TRANSENTERIC DRAINAGE
ENDOSCOPIC ULTRASOUND (EUS)
ALTERNATIVE PROCEDURE AND COST
SUMMARY
REFERENCES
From: Clinical Gastroenterology: An Internist's Illustrated Guide to Gastrointestinal Surgery
Edited by: George Y Wu, Khalid Aziz, and Giles F Whalen © Humana Press Inc., Totowa, NJ
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Upper abdominal pain or distress of insidious onset, often localized to the midepigastrium
is the most frequent symptom (4) Expansion of the pseudocyst may likewise result in
duodenal or biliary obstruction, vascular occlusion, or fistula formation into adjacent
structures such as the viscera, pleura, or pericardium (6) Leakage from the pseudocyst
or pancreatic duct with concomitant fistula formation can result in pancreatic ascites or
a pleural effusion Pseudocyst rupture occurs in less than 3% of patients (7), and may be
clinically asymptomatic However, rupture into the peritoneum can present as an acute
abdominal event necessitating emergent surgery, which is often fatal (8) Erosion into
the gastrointestinal tract may result in hematemesis, melena, or massive hematochezia
(9) Massive bleeding into the gastrointestinal tract occurs in approx 5–10% of patients (10,11), and occurs as a result of pseudocyst erosion into a major pancreatic or
peripancreatic vessel, leading to free rupture or pseudoaneurysm formation (12) The
diagnosis should be suspected in patients with an unexplained drop in hematocrit, rent gastrointestinal bleeding or in the setting of an enlarging pulsatile mass or abdomi-nal bruit in patients with increasing abdominal pain Bolus dynamic CT is the most usefulinitial diagnostic modality to demonstrate the presence of hemorrhage or a pseudo-aneurysm Subsequent angiography is the procedure of choice for isolating the site of
recur-bleeding and directing embolization therapy (11) Surgery is otherwise indicated in
patients who are hemodynamically unstable or when embolization is unsuccessful or
technically not feasible Secondary cyst infection occurs in approx 10% of patients (7).
A confirmatory diagnosis is established on the basis of a positive Gram stain or bacterialisolate from the cyst aspirate in the context of frank pus or sepsis Percutaneous drainage
is successful in approx 85% of cases and should be the initial treatment of choice (13).
pseudocyst size (14).
The role of endoscopic retrograde cholangiopancreatography (ERCP) following thediagnosis of a pancreatic pseudocyst remains controversial Advocates for ERCP havereported a 95% advantage of demonstrating pancreatic ductal abnormalities and an 80%
detection rate for duct-pseudocyst communication (15) Additionally, routine ERCP has
been found to alter the operative plan for pseudocyst drainage in 24 of 41 patients, with
19 requiring a surgical drainage procedure (16) Furthermore, demonstration of ductal
abnormalities, particularly ductal communication or stricturing of the main pancreaticduct plays a major role when considering internal drainage over a percutaneous drainage
procedure (17) In contrast, ERCP has been demonstrated to exacerbate acute
pancreati-tis, resulting in bacterial seeding of fluid collections, and needlessly increase the extent
of operation without a significant advantage in outcome (18,19).
DIFFERENTIAL DIAGNOSIS
Pancreatic pseudocysts comprise approx 75% of all cystic lesions within or adjacent
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congenital cysts (5%), and cystic neoplasm (20) It is essential to distinguish between a
cystic neoplasm, and a pancreatic pseudocyst to determine the specific therapeuticintervention, more specifically, resection rather than a drainage procedure Several guide-lines based on clinical and radiologic criteria have been proposed to differentiate thosewith a greater risk of a cystic neoplasm A cystic lesion is considered to be a probableneoplasm if: 1) there is no antecedent history of pancreatitis; 2) the pancreatogram
is normal on ERCP; 3) there are multiple cysts or internal septae on CT scan; 4) it is ahypervascular tumor as demonstrated on angiography; 5) it is thin-walled, and notadherent to any surrounding tissue at the time of laparotomy; 6) serum amylase levels
are normal; and 7) fluid amylase levels are equal to or lower than serum (21).
Some authors advocate percutaneous aspiration with fluid analysis for viscosity,CA-125, carcinoembryonic antigen (CEA) and cytology CA-125 and CEA levels
have been found to be elevated in neoplastic cysts, and lower in pseudocysts (22).
Cytologic analysis has an accuracy of approx 88% for mucinous cysts and its
diagnos-tic value in serous cystadenomas appears to be limited (23).
(5) Based on these findings, surgery has been a widely accepted approach for cysts that
persist beyond 6 wk However, two additional reviews advocate a more conservativeapproach with expectant follow-up In a retrospective review of 68 patients with asymp-tomatic pseudocysts, approx 63% of patients either had spontaneous pseudocyst resolu-tion or remained asymptomatic at a mean follow-up averaging 51 mo There was a 9%incidence of serious complications including pseudoaneursym formation in three, per-foration in two, and spontaneous abscess formation in one Thirty-five percent of patientsunderwent operative therapy, generally for cyst enlargement associated with pain or
gastric and biliary obstruction (24) In another series of 75 patients, 39 patients
under-went surgery for severe abdominal pain; complications or progressive cyst enlargement,whereas the remaining 36 patients were followed conservatively with serial CT scans Approx60% of patients in the latter group had complete resolution at 1 yr with only one pseudocyst-
related complication of intracystic hemorrhage with no reported mortality (25).
Pseudocyst drainage is indicated in: 1) symptomatic patients; 2) pseudocysts greater
than 6 cm in size or in progressively enlarging cysts; and 3) infected pseudocysts (4).
Immediate drainage can be accomplished safely in patients with mature cysts walls or
with cysts that occur in the setting of chronic pancreatitis (26).
Surgery remains the standard drainage procedure of choice despite the availability ofless-invasive procedures Surgery is associated with a morbidity rate of 10% to 30%,
mortality rate of 1% to 5%, and 10% to 20% recurrence rate (27,28) Endoscopic
drain-age procedures compare favorably to standard operative techniques Similar successrates of 50% and 52% were reported in a retrospective review evaluating surgical man-
agement to endoscopic therapy (29) Comparably, equal rates were found in 71 cases of
endoscopic drainage and 73 cases of surgical drainage, with a reported resolution rate
of 72%, morbidity of 15%, and mortality of 1% (30) These procedures should, however,This is trial version
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be performed on selected patients in experienced centers where surgical back-up isavailable
Endoscopic drainage procedures are extensions of ERCP techniques and consist of:1) tanspapillary; and 2) transenteric or transmural approaches
TRANSPAPILLARY CYSTIC DRAINAGE (TCD)
Transpapillary cyst drainage (TCD) is feasible in the presence of a documentedcommunication between the pseudocyst and pancreatic ductal system Communication
between the pseudocyst and duct occurs in approx 40–69% of pseudocysts (31–33) and
is frequently seen in pseudocysts associated with chronic pancreatitis rather than those
seen with acute pancreatitis (34) An ERCP is performed followed by a pancreatic duct
sphincterotomy with subsequent insertion of a 5–7 Fr stent over a guidewire and left
in situ for a mean of 3 mo (Fig 1) Because of the potential risk of bacterial seeding,
and abscess formation, antibiotic prophylaxis with either Ciprofloxacin or Ceftazidime
(35) is administered preoperatively followed by a 7-d course of oral antibiotics Some
authors recommend the insertion of a nasocystic drain to allow irrigation and drainage
of intracystic debris or pus
In a combined series of 117 patients, successful drainage was accomplished withtranspapillary cystic drainage in 84% of patients with a reported recurrence rate of 9%,
and a complication rate of 12% (36) Procedure-related complications were few with no
reported deaths Bleeding occurred in one patient that did not require intervention Themost frequently encountered complication was acute pancreatitis (6 patients), which,however, was mild and self-limited Stent occlusion was uncommon and secondary
pancreatic cyst infection was seen in 3 patients, which resolved with stent change (37,38) Failures were associated with pancreatic pseudocysts localized to the pancreatic tail (34,
39) There was no added advantage of combined TCD and transmural drainage over TCD
alone (34) Pancreatic ductal irregularities frequently associated with chronic tis are seen in approx 50% of patients following transpapillary stenting (40).
pancreati-TRANSMURAL OR TRANSENTERIC DRAINAGE
Transmural or transenteric endoscopic drainage procedures are performed throughseveral endoscopic approaches through the stomach (endoscopic cystogastrostomy) orduodenum (endoscopic cystoduodenostomy)
Several prerequisites need to be fulfilled pursuant to endoscopic transmural drainage(Table 1) Ideally, the pseudocyst must be situated within the pancreatic head or body,and must be firmly adherent to the gastrointestinal tract to cause a visible impression onthe gastric or duodenal wall at the time of endoscopy Additionally, the distance betweenthe pseudocyst and the adjacent gastric or duodenal wall should not exceed 1 cm on CT
scan or endoscopic ultrasound (41–44).
Cystic neoplasms should be identified and managed appropriately Cystic neoplasmsmanaged inappropriately as pseudocysts may result in serious complications and com-
promise future surgical resection (21,45).
Pseudoaneurysms occur in approx 10% of pseudocysts (12,47,48) and represent an
absolute contraindication to endoscopic intervention, unless arterial embolization has
been accomplished first (6) Gastric varices in the setting of portal hypertension should
be identified to minimize the risk of inadvertent puncture and hemorrhage (49).This is trial version
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Some authors advocate endoscopic needle localization (ENL) or needle aspiration of
a pseudocyst prior to cyst puncture to reduce the risk of bleeding (50) Repeated bloody
aspirate may represent inadvertent puncture of a blood vessel wall or pseudoaneurysmformation and should warrant further investigation prior to any attempt at drainage.Pancreatic necrosis as demonstrated by contrast-enhanced CT might result in inad-equate cyst evacuation, and subsequently increases the risk of infection, and should
serve as a deterrent to, but not preclude endoscopic transmural drainage (51,52).
Endoscopic cystogastrostomies (ECG) and cystoduodenostomies (ECD) require thepuncture of the gastric or duodenal wall at the point of an identifiable impression in thevisceral lumen A side-viewing endoscope is used and access into the cyst is achieved
Fig 1 Transpapillary pancreatic pseudocyst drainage A 5–7 French stent placed after pancreatic
sphincterotomy.
Table 1 Guidelines for Endoscopic Pancreatic Pseudocyst Drainage
1 Cysts must be allowed to mature prior to drainage
2 Assess for the presence of pseudoaneurysm
3 Rule out the presence of a cystic neoplasm
4 Identify gastric varices in the presence of portal hypertension
5 Identify debris within the pseudocyst
6 Outline the pancreatic duct by ERCP
7 The pseudocyst should be in close approximation to the gastric or duodenal wall
8 Utilize a transpapillary approach whenever feasible
9 Endoscopic needle localization should be used prior to puncture
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with a diathermic needle Once entry into the cyst is confirmed, a guidewire is insertedand the opening is enlarged to approx 3–50 mm Balloon tract dilatation has been utilized
to enlarge the opening to reduce the risk of bleeding One or two 7–10 Fr stents aresubsequently inserted into the cyst to maintain patency and are left in place for a meanperiod of 2–4 mo or until ultrasonographic confirmation of cyst resolution occurs (Fig 2)
In a cumulative series of 50 patients who underwent endoscopic cystogastrostomy,successful pseudocyst drainage was achieved in 82 % of patients with a recurrence rate
of 18% Major complications included bleeding in 8%, and perforation in 8% of patientswith no reported deaths The collective incidence of bleeding requiring surgical inter-vention was 7% Bleeding occurred at the time of gastrostomy enlargement with thesphincterotome Small incisions and balloon dilatation of the gastrotomy tract have been
recommended to reduce the risk of these complications (37,42–44).
Concurrently, in a series of 71 patients who underwent ECD, drainage was ful in 89% of patients with a reported recurrence rate of 6%, with a median follow-up
success-of 9–48 mo Complications were less frequent, with perforation in 4% and severebleeding in 4% All three patients that developed perforations were successfully man-aged with antibiotics The overall incidence of bleeding requiring surgery was 3% Intwo reported cases of bleeding, which resulted in one death, bleeding occurred as a
result of a pseudoaneurysm (43) ECD confers the advantage of longer cystoduodenal fistula patency over ECG (41).
ENDOSCOPIC ULTRASOUND (EUS)
EUS offers several advantages over the standard endoscopic drainage procedures (49)
Fig 2 Endoscopic cystgastrostomy Two pigtail stents passed in the pseudocyst through
poste-rior gastric wall.
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three required surgical intervention It is of value in allowing optimal visualization andlocalization of the puncture site in circumstances where there is no visible intraluminal
bulge (54,55) This can be accomplished, however, by endoscopic needle localization,
which provides the same information without interfering with any anticipated
thera-peutic procedures (50).
With the advent of the large-channel therapeutic curvilinear array ultrasoundendoscopes, pseudocyst drainage can be performed solely under sonographic guidance,
thereby obviating the need for separate endoscopies and fluoroscopy (56,57) In the
absence of an adequate pancreatogram performed with the standard procedures, atic strictures and ductal disruptions are likely to be missed resulting in a potentially
pancre-higher rate of pseudocyst recurrence (49).
ALTERNATIVE PROCEDURE AND COST
Pancreatic pseudocyst can also be drained surgical and radiologically Merits anddemerits of these procedures are discussed in detail in Chapter 20 To date, there are nostudies comparing the cost of management of pseudocyst by available techniques
3 Endoscopic drainage is effective in relieving symptoms and has a low complication rate.EUS prior to endoscopic therapy is helpful in delineating the anatomy and ruling outpseudoaneurysm
1 Measures the distance between the pseudocyst and gastrointestinal wall
2 Images gastric varices and submucosal vessels
3 Identifies the presence of pseudoaneurysms
4 Distinguishes between cystic neoplasms and pancreatic pseudocysts
5 Demonstrates the presence of intracystic debris
6 Allow visualization of the puncture site in the absence of an intraluminal bulge
7 Endoscopic drainage may be performed under EUS guidance alone
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